TV medical dramas: health sciences students' viewing habits and potential for teaching issues related to bioethics and professionalism

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Cambra-Badii et al. BMC Medical Education            (2021) 21:509
https://doi.org/10.1186/s12909-021-02947-7

 RESEARCH ARTICLE                                                                                                                                   Open Access

TV medical dramas: health sciences
students’ viewing habits and potential for
teaching issues related to bioethics and
professionalism
Irene Cambra-Badii1,2* , Elisabet Moyano2, Irene Ortega3, Josep-E Baños4 and Mariano Sentí2

  Abstract
  Background: Medical dramas have been popular since their inception, especially among medical students. We
  hypothesized that the recent increase in the availability of TV medical series through online streaming platforms
  has probably changed health science students’ viewing habits as well as the representation of bioethical conflicts
  and health professionals.
  Methods: We invited undergraduate students of medicine, nursing, and human biology to complete a self-
  administered questionnaire about their viewing habits and perceptions of the depictions of bioethical issues and
  professionalism in TV medical series.
  Results: Of the 355 respondents, 98.6 % had watched TV in the last year, 93.5 % watched TV series, and 49.6 %
  watched medical dramas more than once a week. The most-viewed medical dramas were The Good Doctor, House
  MD, and Grey’s Anatomy. The most-remembered bioethical topics were medical errors, inappropriate professional
  behaviors, and death. Most students considered that ideals of professionalism were depicted positively and
  professionals were portrayed as intelligent, professionally qualified, and competent.
  Conclusions: Medical dramas are very popular with health science students and are potentially useful as teaching
  tools for discussing issues related to bioethics and professionalism.
  Keywords: Bioethics, Professionalism, Health sciences students, Television, Medical Dramas

Background                                                                             and relaxation [6]; they are followed by many medical
TV medical dramas have been very popular since their                                   and nursing students [7–10] as well as by clinicians [11].
inception [1–5]. Although most TV medical dramas are                                     These fictional narratives provide concrete medical sit-
produced in the United States and depict situations in                                 uations and are often regarded as a source of health in-
the American health system, they are consumed globally.                                formation by viewers [1, 12]. Several authors have
Medical dramas are mainly watched for entertainment                                    suggested that medical dramas are a potential tool for
                                                                                       teaching students in health sciences disciplines [2, 5, 13,
                                                                                       14]. Baños et al. [15] analyzed the usefulness of House
* Correspondence: irene.cambra@uvic.cat                                                MD for teaching clinical pharmacology. Jerrentrup et al.
1
 Chair in Bioethics, Universitat de Vic – Universitat Central de Catalunya,
                                                                                       [3] also proposed House MD to teach about rare diseases
Carrer Miquel Marti i Pol, 1, 08500 Vic, Spain
2
 Research Group Education in Health Sciences, Department of Experimental               and diagnostic strategies. Williams et al. [16] pointed
and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain                        out several potential uses of House MD, Scrubs, and
Full list of author information is available at the end of the article

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Cambra-Badii et al. BMC Medical Education   (2021) 21:509                                                       Page 2 of 11

Grey’s Anatomy to teach medical problems, medical sys-            Taking into account the previous literature and the ex-
tem issues, psychosocial issues, and relationships with         pansion of series and online platforms, we hypothesized
the patient’s family. Wong et al. [17] successfully used two    that health sciences students watch medical dramas al-
excerpts from House MD and one from Grey´s Anatomy              most daily, that they remember ethical dilemmas and
to teach doctor-patient communication skills, while             how they were portrayed, and that they follow positive
McNeilly and Wengel [18] used ER for teaching psycho-           and negative role models, so medical dramas might
therapeutic techniques to medical students. Hirt et al. [19]    therefore be useful for teaching them bioethics and pro-
suggested Northern Exposure, Cardiac Arrest, ER, Scrubs,        fessionalism. In this study, we sought to determine (a)
House MD, Doc Martin, Grey’s Anatomy, and Nurse Jackie          health science students’ television viewing habits, (b)
in a brief guide for health sciences educators to teach vari-   which medical dramas they have recently viewed, (c)
ous themes such as mentorship, hospital environments,           their motives for watching medical dramas, (d) the eth-
teaching and learning, and professionalism.                     ical issues portrayed in the dramas that they recall, and
  Specifically for analyzing and teaching professionalism       (e) the characteristics of the health professionals’ por-
and bioethical issues, medical dramas were especially ex-       trayed in the dramas that determine whether students’
plored in the last decade. Czarny et al. [20] performed a       consider them positive or negative role models.
content analysis of 50 episodes of Grey’s Anatomy and
House MD during the 2005–2006 television season and
                                                                Methods
found 79 depictions of bioethical issues classified under 11
                                                                Study population
topics, including consent, ethically questionable depar-
                                                                This study surveyed all undergraduate students of medi-
tures from standard practice, death and dying, and confi-
                                                                cine, nursing, and human biology at our University dur-
dentiality. Cambra Badii et al. [21] performed a content
                                                                ing the 2018–2019 academic year. Inclusion criteria
analysis of the first season of The Good Doctor and found
                                                                were participation in classroom activities at the time of
179 situations that can be used to teach bioethics. Arawi
                                                                the survey and consent to participate in the study. Exclu-
[22] proposed to work with Grey’s Anatomy and House
                                                                sion criteria were not explicitly established other than
MD vignettes to teach biomedical ethics, and Pavlov and
                                                                the lack of compliance with inclusion criteria. The final
Dalquist [23] used Grey’s Anatomy to teach communica-
                                                                sample population included all students enrolled in the
tion and professionalism. Moreover, Spike [24] pointed
                                                                6-year Bachelor of Medicine program, in the first 3 years
out the bioethical issues involved in a doctor–patient
                                                                of the 4-year Bachelor in Nursing program, and in all
communication and medical errors in Scrubs.
                                                                years of the 4-year Bachelor in Human Biology. Fourth-
  The portrayals of health professionals that appear in
                                                                year nursing students were not included because the
medical dramas are also interesting, because they were
                                                                fourth year of this program is dedicated to clinical train-
changing over the years [5, 14, 25]. Chory-Assad and
                                                                ing and does not include classroom activities. Medical
Tamborini [26, 27] demonstrated the decline in positive
                                                                students begin clinical training in the fourth year, but
portrayals of physicians in television since the 1990 s, and
                                                                continue to have classroom activities thereafter, and stu-
Czarny et al. [20] showed up clearly anomalous portrayals
                                                                dents of human biology do not undergo clinical training.
of professionalism in House MD and Grey’s Anatomy.
  These portrayals can be used to analyze or discuss pro-
fessionalism because they offers positive models of behav-      Study design
ior, like Miranda Bailey and Derek Sheperd from Grey’s          We adapted Czarny’s medical TV drama survey [10], de-
Anatomy, or Allison Cameron and James Wilson from               signed to gather data on basic demographic characteris-
House MD [9]. Even complex and negative models, like            tics, general TV and TV medical drama viewing habits,
Doctor House in House MD, can be useful to teach profes-        impressions of bioethical and professionalism issues in
sionalism, but in this case, from his mistakes [9, 20]. Sem-    medical dramas, and sources of information on bio-
inal studies of television viewing habits of health sciences    ethical issues (Additional file 1).
students have provided interesting information about               Medical dramas considered in the study were ER,
health sciences students’ TV viewing habits [7, 9, 10].         House MD, Grey’s Anatomy, NipTuck and Scrubs like in
However, in the last 10 years, the growing popularity of        previous studies [7, 9, 10]. We have added the most
online platforms such as Netflix, HBO, Hulu, and Amazon         newest medical dramas aired in Spain at the time of the
Prime has drastically changed the way that TV series are        survey, The Good Doctor and The Resident. Students
produced and consumed [28]. It is likely that these devel-      could add other medical dramas in an open field. We
opments have changed health sciences students’ TV view-         modified some questions about TV shows and the char-
ing habits, and it is possible that they have also affected     acters that students most and least wish to resemble in
their impressions of bioethical issues and the portrayal of     their professional lives to make them open-ended and
healthcare professionals in medical series.                     adding some questions about the reasons for watching
Cambra-Badii et al. BMC Medical Education   (2021) 21:509                                                   Page 3 of 11

medical series [6] and the portrayal of doctors and            All tests were two-tailed, and statistical significance
nurses in medical dramas [26].                               was set at 0.05. Microsoft Office Excel 2007 and SPSS
  To ascertain whether the wording or the questions          (version 16) were used for all analyses.
should be changed, we pilot-tested the survey on ten
members of the research team. They were experi-              Results
enced researchers in the field of biomedical research        Study population
education and members of the Group for Educative             A total of 355 of 918 students participated in the survey;
Research in Health Sciences of our university. Based         responses were obtained from 124/339 (36.6 %) of eli-
on this feedback, we reformatted the survey to im-           gible medical students, 143/381 (37.5 %) of eligible nurs-
prove clarity.                                               ing students, and 88/198 (44.4 %) of eligible human
                                                             biology students (Table 1). Women accounted for 78.5 %
                                                             of the respondents, and the proportion of women partic-
Data collection
                                                             ipants was similar in the three programs, coinciding with
We used the Google Forms platform to draft the
                                                             the distribution of women in the three programs. Mean
questionnaire and conduct the survey; participants
                                                             age did not differ between groups of students from the
could complete the questionnaire between February
                                                             different programs, although the age range was broader
13 and April 8, 2019. We ensured that each respond-
                                                             in the group of nursing students than in the other two
ent provided only one response by controlling the
                                                             groups.
login in Google Forms in the different classrooms,
while guaranteeing anonymity.
                                                             Television viewing habits
  The study was performed according to the principles
                                                             Nearly all respondents (98.6 %) reported watching TV in
of the Declaration of Helsinki. Data confidentiality was
                                                             the last year; the most-watched shows were TV series
ensured according to local legislation on the protection
                                                             (93.5 %), followed by movies (86.8 %), news (67.9 %), and
of personal data.
                                                             sports (34.7 %) (Table 2). There were no differences be-
  Before starting the survey, students were read an infor-
                                                             tween genders except women in the nursing program
mation sheet explaining the background, aims, and pro-
                                                             watched less news and sports (p < 0.05).
cedure of the study, and they were informed that the
                                                               Nearly half (49.6 %) the students watched medical
bioethics committee had approved the study protocol
                                                             dramas. There were no differences in the frequency of
and that participation was voluntary.
                                                             viewing among the different programs.
                                                               The most common way of watching medical dramas
Data analysis                                                was through online platforms (listed by 78.1 % of re-
We used descriptive statistics to summarize participants’    spondents: of whom 41.7 % used Netflix, 23.7 % used
demographic characteristics and data obtained from the       Movistar, 9.9 % used HBO, and 2.8 % used Amazon),
survey. To compare categorical variables between groups      followed by regular TV episodes (24.2 %), regular TV
(men vs. women; medical students vs. nursing students        reruns (16.3 %), pirate streaming (11.5 %), and DVD
vs. human biology students; preclinical vs. clinical med-    (1.4 %).
ical students), we used chi-square tests.                      In the last year, the most-watched medical dramas
  In analyzing our data, we dichotomized responses for       were The Good Doctor (47 %), House MD (41.4 %), and
three items. For the frequency of viewing medical series,    Grey’s Anatomy (38 %), followed by The Resident (7.9 %),
we grouped all responses indicating viewing > 1 under        ER (6.8 %), and Scrubs (5.9 %). No series included in the
the category “frequently” [9]. For questions answered on     open field “other medical series” reached a significant
a five-item Likert scale (those regarding the reasons for    frequency to be included in the analysis, but Chicago
viewing medical dramas and the representation of ethical     Med, Code Black and Nurse Jackie were mentioned a
issues), the responses “totally agree” and “agree” were      total of 16 times.
grouped together into the category “yes”, and the re-          Gender differences were observed only for Grey’s
sponses “neither agree nor disagree”, “disagree”, and        Anatomy, watched by 44.7 % of women but only 13.1 %
“strongly disagree” were grouped into the category “no”.     of men. The difference was even greater among medical
Similarly, the responses about the appropriateness of the    students (46.5 % of women vs. 8.3 % men, p < 0.001). No
depiction of each of the different ethical issues in the     differences were found in the medical dramas watched
medical series, the responses “barely” and “below accept-    between students’ in different years within academic
able” were grouped together into the category “poorly        programs.
represented”, while the responses “appropriate” and            Asked whether they discuss medical aspects of the
“very appropriate” were grouped together as “well            series with their friends, 57.8 % of all participants
represented”.                                                responded affirmatively. The reasons most often given
Cambra-Badii et al. BMC Medical Education        (2021) 21:509                                                           Page 4 of 11

Table 1 Characteristics of the study sample
Undergraduate program                       Gender, n (%)                                Age, mean (SD)              Year, mean (SD)
                                            M                    F
Medicine                                    36 (29.5)            86 (70.5)               22.1 (0.4)                  3.8 (1.7)
Nursing                                     21 (14.7)            122 (85.3)              21.0 (3.4)                  1.8 (0.8)
Human Biology                               19 (21.6)            69 (78.4)               19.8 (0.2)                  2.4 (1.1)

for watching medical dramas were entertainment                          activities (5.1 %), and elective subjects (2.3 %); 15.5 % of
(96.6 %) and medical information (89.2 %), followed by                  respondents stated that they had received no informa-
habitual pastime/companionship (76.5 %), and relaxation                 tion from the university about bioethical issues.
(68 %).                                                                    The sources of information on bioethics considered
                                                                        most important were the university (91.3 %) and scien-
Ethical issues                                                          tific journals (86.8 %), followed by friends (76.4 %) and
Most students (56.9 %) considered that the medical                      medical dramas (63.6 %). The sources considered less
series did not adequately portray the bioethical issues                 important were ecclesiastical staff, religious values, and
that appear in clinical practice. The bioethical issues re-             blogs. There were no differences between genders. There
membered best were medical errors (66.5 %), inappropri-                 were no differences between fields of study, except med-
ate professional behavior (58.3 %), and death (59.4 %),                 ical students gave significantly lower importance to sci-
followed by confidentiality (49 %), quality or value of life            entific journals and religious values.
(48.2 %), infectious diseases (45.9 %), and access to and
equity in health care (40.8 %). The least-mentioned is-                 Portrayals of health professionals
sues were harassment (29.3 %), education for healthcare                 Most students believed that all ideals of professionalism
professionals (25.6 %), non-therapeutic methods (24.8 %),               were depicted positively in medical dramas. Doctors
and human research (22.3 %) (Table 3).                                  were portrayed positively in medical dramas; respon-
   The ethical issues that were considered the best por-                dents referred to their intelligence (97.3 %), professional
trayed in the medical dramas differed among the groups.                 qualification (93.6 %), and competence (90.5 %). Nurses
Medical students most often listed death (65.9 %), infec-               were also portrayed positively; respondents most often
tious diseases (62.7 %), and quality or value of life                   referred to their kindness (75.8 %), empathy (74.5 %),
(62.1 %); nursing students most often listed organ trans-               and caring (74.3 %).
plantation (67 %), death (62.5 %), and quality or value of                The survey asked about which characters the students
life (59.3 %); and human biology students most often                    aspire to be like in their professional careers, and they
listed death (84 %), infectious diseases (81.6 %), and                  responded none (9.9 %), Dr. Meredith Grey (from Grey’s
organ transplantation (80.9 %).                                         Anatomy) (5.6 %), and Dr. Gregory House (from House
   Similarly, the ethical issues considered badly repre-                MD) (2.5 %). Students of human biology tended to want
sented listed by medical students were non-therapeutic                  to resemble Dr. House more than medical students and
medical uses (65.1 %), human research (64.3 %), and edu-                nurses.
cation of health professionals (58.8 %); those listed by                  The characters they least aspired to be like were Dr.
nursing students were human research (64.1 %), access                   Gregory House (from House MD) (18.6 %) and Cristina
to and equity in health care (63.2 %), and non-                         Yang (1.4 %) and April Kepner (1.1 %) (both from Grey’s
therapeutic medical uses (62.5 %); and those listed by                  Anatomy). The most-chosen negative characteristics
human biology students were access to and equity in                     were lack of intelligence (55.1 %), lack of professional
health care (65.9 %), human research (59.5 %), and har-                 qualification (53.1 %), and lack of competence (42.2 %).
assment (51.1 %).
   There were no significant differences between clinical               Discussion
and preclinical medical students regarding the represen-                More than 12 years after Czarny et al.’s original survey
tation of bioethical issues: 45.2 % of preclinical students             of health science students’ TV viewing habits [10], we
and 54.8 % of clinical students responded that these is-                found that nearly all health sciences students had
sues were well represented.                                             watched TV in the last year, corroborating the findings
                                                                        of other studies in the interim [7, 9]. Moreover, TV
Sources of bioethical information                                       medical dramas were the type of program that students’
The information about bioethics that students received                  watched most. This is a notable difference with Weaver
during their university education came mostly in com-                   and Wilson’s study [9], where medical dramas were the
pulsory subjects (52.4 %), followed by extracurricular                  least-watched category (films were the most-watched
Cambra-Badii et al. BMC Medical Education

Table 2 Health science students’ TV viewing
Academic     Watch TV            Type of TV program                                                          Watch medical dramas       Format                                       Frequency
program                                                                                                                                                                              (>1 time
                                 Series              Movies             News              Sports             Total                      Regular          Reruns      DVD Online
                                                                                                                                                                                                     (2021) 21:509

                                                                                                                                                                                     p/week)
                                                                                                                                        episodes on TV   on TV           platforms
Medicine     M 35      F 86      M 30      F 83      M 34      F 76     M 29     F 68     M 18     F 30      57      M 12     F 45      10 (17.5)        15 (26.3)   1       54 **   36 (29)
             (97.2)    (100)     (83.3)    (9.5)     (94.4)    (88.4)   (8.6)    (79.1)   (50)     (3.9)     (46)    (33.3)   (52.3)*                                (1.8)
Nursing      M 20      F 122     M 20      F 115     M 17      F 96     M 17     F 66     M 13     F 29      80     M6        F 74      32 (40)          13 (16.3)   1       94**    78 (54.5)$
             (95.2)    (100)     (95.2)    (94.3)    (81)      (78.7)   (81)     (54)*    (61.9)   (23.8)*   (55.9) (28.6)    (70.7)*                                (1,3)
Human        M 18      F 68      M 18      F 65      M 19      F 65     M 15     F 45     M 10     F 22      39     M3        F 36      13 (33.3)        12 (30.8)   --      42**    25 (28.4)
Biology      (94.7)    (98.6)    (94.7)    (94.2)    (100)     (94.2)   (78.9)   (65.2)   (52.6)   (32.4)    (44.3) (15.8)    (52.2)*
Data are expressed as number of cases and percentages in parentheses.
*
  Significantly different between genders, p < 0.05
**
   Significantly different from other formats, p < 0.05
$
  Significantly different from other academic programs
                                                                                                                                                                                                       Page 5 of 11
Cambra-Badii et al. BMC Medical Education

Table 3 Recall of ethical issues in TV medical dramas
                                                                                                                                                                                                    (2021) 21:509

                   Access to     Medical          Infectious       Quality /     Non-          Education for   Informed      Human      Artificial and     Death     Discrimination Harassment
                   and equity in errors           diseases         Value of      therapeutic   healthcare      consent       research   transplanted       and dying
                   health care                                     life          methods       professionals                            organs / tissues
                   M        F        M     F      M       F        M      F      M      F      M       F       M      F      M    F     M        F         M    F    M      F      M      F
Medicine           52.8     50       61.1 69.8 50         47.7     38.9   41.9   30.6   25.6   30.6    30.2    33.3   44.2   13.9 23.3 38.9      40.7      52.8 60.5 44.4   40.7   33.3   26.7
Nursing            33.3*    32       66.7 68.9 52.4       42.6     52.4   53.3   38.1   22.1   33.3    25.5    28.6   40.2   42.9 19.7 47.6      48.4      57.1 64.8 38.1   48.4   33.3   30.3
Human Biology 47.4          37.7     47.4 66.7 31.6       50.7     42.1   52.2   15.8   24.6   15.8    26.1    42.1   40.6   21.1 24.6 42.1      44.9      36.8 58   36.8   33.3   26.3   27.5
Data are expressed as percentages
*
  Significantly different from other academic programs, P < 0.05
                                                                                                                                                                                                      Page 6 of 11
Cambra-Badii et al. BMC Medical Education   (2021) 21:509                                                       Page 7 of 11

category). This difference could be explained by the in-        and Taylor’s factor analysis of data from students en-
creased number of TV series and their availability              rolled in communications courses [6], where social inter-
through online platforms (e.g., Netflix); students now          action, relaxation, and entertainment motives were
have greater freedom to choose what they want to see.           significant predictors of viewing time. In the current
   Nevertheless, the percentage of students who said they       study, the salient motives were entertainment and med-
watch medical series (49.6 %) was much lower than in            ical information. The sources of information on bio-
earlier studies (> 80 % in all), although we asked specific-    ethical issues considered most important in the current
ally about medical dramas, which can be considered a            study are in line with those reported in previous studies
subgenre of medical programs. We cannot know                    [7, 10], underlining the importance of the university and
whether these findings represent a change of health sci-        scientific journals. However, in the second line, friend-
ence students’ interests or whether they are a conse-           ships have replaced family. Medical dramas continued to
quence of the proliferation of programs and series in           hold the third place, as in Williams’ [7] and Czarny’s
various genres.                                                 [10] studies, although it is interesting to note that
   The medical drama that health science students               whereas less than 50 % of respondents in their studies
watched most was The Good Doctor, one of the newest             considered medical dramas an important source of in-
medical dramas (available since 2017). This series shows        formation about bioethical issues, more than 60 % of
the life of a young autistic physician with savant syn-         those in our study considered these programs important.
drome who is starting his residency in surgery, and it in-         Over half the respondents in our study considered that
cludes many situations that involve bioethical issues           the ethical issues that appear in medical dramas were
[21]. The Good Doctor approaches medical issues from a          not adequately depicted. We can only speculate about
different point of view than other popular medical              the reasons for this finding, which is similar to that re-
dramas, and the originality of using an autistic resident       ported in previous investigations [7, 9, 10], although the
as the main character probably adds to its appeal.              study populations were different. Perhaps students con-
   Two of the most-viewed series in previous surveys            sider that medical dramas are unrealistic. It is important
were also among the most popular in the current study:          to note that students recall the ethical issues portrayed
House MD, which aired from 2008 to 2012, and Grey’s             in medical dramas even some time after viewing and
Anatomy, which has aired from 2005 and is now in its            consider that they are not correctly represented. Given
16th season. Why do students continue to watch these            that nearly half the students discuss medical issues with
TV series? House MD is considered one of the best med-          friends and that “social activity may facilitate the forma-
ical dramas with an iconic protagonist [3, 7–10, 17, 29]        tion of new opinions and perceptions” [10], it seems that
and, like Grey’s Anatomy, it is distributed by Netflix, one     medical dramas play a role in forming views about bio-
of the most popular media-services providers, with              ethics and appropriate behavior for health professionals.
193 million subscribers around the world in 2020 [30].             We analyzed the portrayal of medical doctors and
Our study also corroborates the findings in previous re-        nurses in medical dramas and the characteristics of these
search [9, 10] that Grey’s Anatomy was the only medical         professionals that the students consider positive. Both
drama for which there were differences in viewing be-           professions were viewed positively. The characters in
tween the sexes. A greater proportion of women than             medical dramas have changed over the last 25 years,
men watched this medical drama, perhaps because the             evolving from idealized representations of “medical her-
main character is a woman and the storyline revolves            oes” to more complex representations of professionals
around social and love relationships and the daily chal-        with flaws and interpersonal problems, even to the point
lenges of clinical practice in a hospital [13]. Nevertheless,   of including “antiheroes” [25–27, 31]. These changes
the percentage of women who regularly follow Grey’s             seem to point to an increased focus on negative charac-
Anatomy in our survey (44.7 %) is clearly lower than in         teristics of physicians in current medical dramas; as
Czarny’s study (81 %) but close to and Weaver and Wil-          Chory-Assad and Tamborrini [26, 27] demonstrated,
son’s (48.2 %) survey. The drop in the consumption of           positive portrayals of physicians in television programs
this medical drama could be due to the age of the series        have declined since the 1990 s. However, students of
(it debuted in 2005) as well as to the wide availability of     health sciences continue to consider that the protago-
competing offerings. The series ER and Scrubs, found to         nists of these TV series are positively represented.
be popular in previous research [7–9], were not among              It is striking that we found the least-represented char-
the most-watched programs in the present study, prob-           acteristics of the physicians in medical dramas were em-
ably because they are not currently available on online         pathy, emotional involvement, and kindness. Our results
viewing platforms.                                              agree partially with those of Chory-Assad and Tamborri-
   The most important reasons for viewing medical               ni’s earlier studies [26, 27] although their analyses in-
dramas in our study were different from those in Lee            cluded the representation of doctors in different types of
Cambra-Badii et al. BMC Medical Education   (2021) 21:509                                                     Page 8 of 11

television programs, not only medical dramas. Like in         communication skills [2, 16, 19]. Medical dramas can
our study, “competence” was an important characteristic       also be considered part of the hidden and informal cur-
of TV physicians in their studies; however, they found        ricula of medical ethics [40–42], which is at least as im-
that “ethical character” and “regard for others” were also    portant as formal education in ethics [10]. Given the
portrayed. These findings highlight a shift in emphasis       importance of compulsory subjects in health sciences
toward knowledge derived from evidence-based medi-            degrees in teaching of bioethics, incorporating medical
cine to the detriment of clinical skills needed to care for   dramas into these classes could be a good approach to
patients [32].                                                exploiting this material.
  As in Weaver and Wilson’s study [9], the characters            Students can absorb the educational messages in med-
students would most like to resemble continue to be the       ical dramas when they view them for entertainment. In
protagonists of House MD and Grey’s Anatomy, the              fact, even though they were not created specifically for
most-viewed medical dramas. Also, Dr. Gregory House           education, these programs can be seen as an
ranked highly both as someone students most and least         entertainment-education tool [43, 44]. In entertainment-
aspired to be like in their own careers. The importance       education shows, viewers are exposed to educational
of this character should not be underestimated: despite       content in entertainment contexts, using visual language
his questionable professionalism evident in his constant      that is easy to understand and triggers emotional en-
disregard for the rules and avoidance of contact with his     gagement [45]. The enhanced emotional engagement
patients [33, 34], health sciences students value House’s     and cognitive development [5] and moral imagination
knowledge and intelligence [3, 29].                           make students more sensitive to training [22]. Previous
  The characters that respondents from all three pro-         investigations about entertainment-education medical
grams of study said they would most like to resemble          dramas and social learning theory indicate that these
were all medical doctors. The fact that respondents did       programs can increase knowledge about health matters,
not choose any nursing characters invites speculation         for example about early breast cancer detection [46].
about the roles of doctors and nurses in TV medical              Albert Bandura’s social learning theory [47–49] indi-
dramas. Whereas the characteristics most often cited to       cates that people can learn behaviors vicariously by
describe physicians in these series were intelligence, pro-   watching and thinking about characters’ behaviors. In
fessional qualification, and competence, those most often     entertainment-education medical drama, the characters
cited to describe nurses were friendliness, empathy, and      can serve as positive or negative models to teach desir-
caring. These portrayals have been analyzed various           able professional behavior [9, 10].
times in relation with the different roles of physicians         Rather than merely passive observers, health science
and nurses as well as with poor, incorrect, or misleading     students are active viewers who notice positive and also
portrayals of nursing role models [8, 35] in which stereo-    negative characteristics of physicians and nurses. In this
types abound, especially in relation to gender roles [36].    sense, students can decide whether characters’ behavior
Nurses are rarely the protagonists of medical dramas          should be emulated or criticized, as well as which char-
and are even “invisible” in many TV dramas [37]; more-        acters might serve as positive or negative role models.
over, nurses are often wrongly characterized as only fe-      Also, students point out that bioethical dilemmas are
males and as underlings who are not involved in               sometimes poorly represented (overall, students most
decision making.                                              often mentioned inadequate representation of bioethical
  Our results show that medical dramas could be useful        issues related to human research, non-therapeutic
for teaching bioethics. Because these programs are seen       methods, and equity of access to healthcare) and this im-
by many students, have an interesting and entertaining        plies that they critically see portrayal of bioethical di-
format, depict bioethical conflicts that students remem-      lemmas and the character actions in resolving these
ber and characters they want to resemble, TV medical          dilemmas. As Spike points out [24], these TV series ad-
dramas can be considered a valuable tool to help stu-         here to the Hollywood paradigm of morality tale and
dents reflect on bioethics. Many TV series present di-        may be valuable aids to thinking about ethics and pro-
verse situations in each episode that can be used to          fessionalism. Although it is difficult to determine the ef-
teach ethics, although it is essential to analyze the con-    fects of medical dramas on students’ attitudes, our study
tent and to establish the suitability of the material for     confirms their popularity.
each pedagogical objective [38, 39].                             Some authors consider that TV series can have nega-
  Students’ interest in medical dramas suggests that          tive influences on students because they could be unreal-
these programs can also be considered in developing           istic or even potentially harmful and dangerous [34, 50],
new teaching strategies. These materials can be useful        basically because of unreal or inaccurate depictions of
for exploring transversal issues, such as medical profes-     hospital procedures and professional practice; however,
sionalism, doctor-patient relationship, bioethics, and        we consider that rather than focusing on the authenticity
Cambra-Badii et al. BMC Medical Education   (2021) 21:509                                                        Page 9 of 11

of medical procedures, teaching based on medical series         patient care, when they have to remember and repro-
should focus on the plausibility of the situations that are     duce for the action themselves.
presented [51]. The issues depicted in medical dramas              Finally, some limitations of our study should be out-
are useful for exploring moral judgments beyond veri-           lined. First, it was limited to a sample of health sciences
similitude [29], although they may not be very useful for       students of some disciplines at a single university. Our
teaching practical skills [50] except to criticize mistakes.    study can be expanded in future research to include
In any case, studies comparing the pedagogical efficacy         more students from the same university or students at
of medical dramas and other narrative resources could           various universities on different continents. Moreover,
provide valuable information.                                   only about 50% of the students responded, probably be-
   Future research must apply a systematic approach to          cause participation was voluntary, but we consider that
evaluate the pedagogical impact of medical dramas. Al-          was adequate to obtain sound conclusions. In fact, get-
though there are some previous experiences [17, 18, 22],        ting good responses to surveys is a challenging issue. Be-
there is a lack of systematization in the development of        sides, the majority of respondents were women but this
these activities and in the measurements of empirical re-       was expected as most of students of health sciences in
sults; moreover, the approach to the pedagogical inter-         our country are female.
pretation of this impact should also be considered                 It would be interesting to explore the effects of cogni-
systematically, for example using Kirkpatrick’s learning        tive maturity on students’ responses; however, this im-
levels [52, 53].                                                portant issue should be considered in a study specifically
   The large number of health science students that             designed to determine the effect of cognitive maturity in
watch TV series and medical dramas in particular                each group of students. Also, it could be interesting to
strongly suggests that students find these programs at-         analyze the impact of local TV series to analyze bio-
tractive, which in turn makes them attractive for teach-        ethical issues outside the context of the United States
ing If we interpret this association according to               [50, 54], and to analyze the impact of non-fictional pro-
Kirkpatrick’s learning levels, it seems clear that the use      grams. Moreover, it could be interesting to analyze the
of series in teaching of health sciences would easily fulfill   possible influence of medical dramas in young profes-
the first level, of reaction. A positive reaction to the        sionals’ attitudes and behaviors [8, 11] as well as the pos-
teaching activities is essential: although it does not guar-    sible impact on young people’s desire to become
antee learning by itself, it serves to validate the experi-     healthcare professionals.
ence [52]. Future studies should evaluate teaching
experiences through short- and long-term outcomes,              Conclusions
measuring not only student satisfaction (Kirkpatrick’s          We conclude that medical dramas are of considerable
first level), but also knowledge acquisition (Kirkpatrick’s     importance and relevance to students. Nearly all health
second level) and even skills acquisition on the behav-         sciences students watched television in the last year, and
ioral level (Kirkpatrick’s third level). This is especially     nearly half of them students watched medical dramas
important in relation to teaching bioethical issues that        frequently. Students remember bioethical issues dis-
health science students already observe, remember, and          cussed in television series, and most students believed
criticize from medical series. These medical dramas             that all ideals of professionalism were depicted positively
could model behavior. It is striking that the most-             in medical dramas.
remembered ethical issue was medical errors, followed              The results of the current study show the effects of the
by inappropriate professional behavior. As we pointed           huge increase in the availability of TV medical series
out above, these are opportunities to learn through good        through online platforms on the viewing habits of health
or bad models, so they can be included in classes to            science students. These students are big consumers of
teach patient safety or other specific subjects with an ap-     TV series, especially on new platforms. These resources
propriate evaluation method. We recommend strict                are very accessible, allowing students to watch episodes
measurement of the effectiveness of teaching activities as      of current or previously broadcast series as often as they
well as comparison with standard pedagogical methods.           like and as many times as they like. Students can view
   As Law et al. [43] pointed out, it would be important        them on various devices (televisions, computers, tablets,
to take into account long-term evaluations to address           smart phones, etc.), alone or with their friends and
Kirkpatrick’s third (behavior) and fourth (results) learn-      families.
ing levels. This approach involves not only measuring              Medical dramas can be useful for teaching issues re-
how medical dramas can lead to knowledge and skills             lated to bioethical questions and professional practice in
acquisition, but also how this acquisition can be trans-        health sciences. Depending on their educational objec-
lated into students’ behavior in concrete situations, such      tives, teaching initiatives could use an entire season, an
as in workplace-based assessments or simulations about          episode, or a shorter edited clip. It is important to
Cambra-Badii et al. BMC Medical Education              (2021) 21:509                                                                                   Page 10 of 11

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1
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Carrer Miquel Marti i Pol, 1, 08500 Vic, Spain. 2Research Group Education in             0.1136/jme.2009.033621.
Health Sciences, Department of Experimental and Health Sciences,                   21.   Cambra-Badii I, Pinar A, Baños JE. The Good Doctor and bioethical
Universitat Pompeu Fabra, Barcelona, Spain. 3School of Health and Life                   principles: a content analysis. Educ Med. 2020. https://doi.org/10.1016/j.
Sciences, Universitat Pompeu Fabra, Barcelona, Spain. 4School of Medicine,               edumed.2019.12.006.
Universitat de Vic – Universitat Central de Catalunya, Vic, Spain.                 22.   Arawi T. Using medical drama to teach biomedical ethics to medical
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Received: 20 November 2020 Accepted: 15 September 2021                                   003697457.
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